Pathological

The Times reports that 11% of kids, including 19% of high-school-age boys, are now diagnosed with attention deficit hyperactivity disorder (ADHD). Those are stunning numbers. Does anyone believe that that many kids are suffering from a diagnosable mental illness?

The article disappoints in its discussion of why. It briefly blames parents who want to gain a competitive academic edge for their kids—“some parents are pressuring doctors to help with their children’s troublesome behavior and slipping grades.” There is no discussion at all of the role of education policy—specifically high-stakes testing—in pushing kids toward these diagnoses.
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Buy now, pay later

One thing that drives me crazy is when people use a narrowly-defined short-term “gain” to justify intervening in kids’ lives, without regard to the long-term consequences. Using elaborate reward systems means fewer referrals to the principal’s office! Piling on homework will raise third-grade standardized test scores! Even if there were evidence to support these assertions, who would define success so narrowly? I’d much rather raise a kid who enjoys reading than one whose third-grade test scores are higher but who thinks of reading as a chore.

I’ve been meaning for some time to link to this article by Marcia Angell in the New York Review of Books. It reviews three books that discuss the increasing diagnosis of mental illness and the corresponding increase in the use of psychiatric drugs. If what the authors say is true, the story is basically one long parade of short-term thinking at the expense of long-term well-being, with a big dose of corporate avarice and bad government policy driving it all:

For obvious reasons, drug companies make very sure that their positive studies are published in medical journals and doctors know about them, while the negative ones often languish unseen within the FDA, which regards them as proprietary and therefore confidential. This practice greatly biases the medical literature, medical education, and treatment decisions.

. . .

Whereas [Irving] Kirsch concludes that antidepressants are probably no more effective than placebos, [Robert] Whitaker concludes that they and most of the other psychoactive drugs are not only ineffective but harmful.

. . .

Moreover, Whitaker contends, the natural history of mental illness has changed. Whereas conditions such as schizophrenia and depression were once mainly self-limited or episodic, with each episode usually lasting no more than six months and interspersed with long periods of normalcy, the conditions are now chronic and lifelong. Whitaker believes that this might be because drugs, even those that relieve symptoms in the short term, cause long-term mental harms that continue after the underlying illness would have naturally resolved.

The review then specifically focuses on the increasing use of psychiatric drugs on children:

What should be of greatest concern for Americans is the astonishing rise in the diagnosis and treatment of mental illness in children, sometimes as young as two years old.

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The apparent prevalence of “juvenile bipolar disorder” jumped forty-fold between 1993 and 2004, and that of “autism” increased from one in five hundred children to one in ninety over the same decade. Ten percent of ten-year-old boys now take daily stimulants for ADHD—“attention deficit/hyperactivity disorder”—and 500,000 children take antipsychotic drugs.

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One would be hard pressed to find a two-year-old who is not sometimes irritable, a boy in fifth grade who is not sometimes inattentive, or a girl in middle school who is not anxious. (Imagine what taking a drug that causes obesity would do to such a girl.) Whether such children are labeled as having a mental disorder and treated with prescription drugs depends a lot on who they are and the pressures their parents face. As low-income families experience growing economic hardship, many are finding that applying for Supplemental Security Income (SSI) payments on the basis of mental disability is the only way to survive.

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In December 2006 a four-year-old child named Rebecca Riley died in a small town near Boston from a combination of Clonidine and Depakote, which she had been prescribed, along with Seroquel, to treat “ADHD” and “bipolar disorder”—diagnoses she received when she was two years old.

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Rebecca’s two older siblings had been given the same diagnoses and were each taking three psychoactive drugs. The parents had obtained SSI benefits for the siblings and for themselves, and were applying for benefits for Rebecca when she died. The family’s total income from SSI was about $30,000 per year.

The whole thing is really a must-read. Part 1 is here; part 2 is here.
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Ordinary people

Here’s another installment in Peter Gray’s series on whether ADHD should (in the wide majority of cases, at least) be considered a “disorder.” An excerpt:

My goal in that [previous] essay was to explain the extraordinary increase in rate of ADHD diagnosis that has occurred over the last two or three decades. I don’t think that increase is primarily due to a change in brain structures in the general population; I think it is primarily due to a change in social values and especially in the conditions of schooling. Today, as a society, we are far less tolerant of children who don’t adapt well to our system of compulsory education than we were in the past, and so we diagnose them and give them drugs.

For a somewhat (but not fully) analogous case, consider homosexuality. Homosexuality is biologically a condition of the brain; but the decision to label it as a disorder, or not a disorder, is a social judgment. Until 1973, homosexuality was on the American Psychiatric Association’s list of official mental disorders, but in that year it was removed. Suddenly, gay people were no longer “disordered.” That decision clearly reflected a change in social values, a change that made it possible for people with the brain condition of homosexuality to live happier lives than they had been able to before, when they more or less had to stay in the closet and were subject to terrible abuse and even arrest if they did not. With regard to homosexuality we have as a society become more liberal and accepting. With regard to the kind of childhood rambunctiousness and impulsiveness that leads to a diagnosis of ADHD, however, we have as a society become less liberal and accepting.

He concludes that “our focus should be on changing our system of schooling to accommodate children’s diversity rather than on changing children’s brain physiology to accommodate schooling.” Worth reading in full.


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Morphine and the bed of nails

In her essay “Facing Reality,” Marilynne Robinson (often quoted here) wrote about our society’s increasing tendency to medicalize emotional states. As I read Peter Gray’s post about how thirteen percent of American boys have been diagnosed with ADHD, I couldn’t help but think of these lines from Robinson’s essay:

To say that behavior is aberrant is much more powerfully coercive among us than to say an action is wrong. . . .

Antebellum doctors described an illness typical of enslaved people sold away from their families, which anyone can recognize as rage and grief. By medicalizing their condition, the culture was able to refuse the meaning of their suffering. I am afraid we are also forgetting that emotions signify, that they are much fuller of meaning than language, that they interpret the world to us and us to other people. Perhaps the reality we have made fills certain of us, and of our children, with rage and grief -- the tedium and meagerness of it, the meanness of it, the stain of fearfulness it leaves everywhere. It may be necessary to offer ourselves palliatives, but it is drastically wrong to offer or to accept a palliative as if it were a cure.

And earlier in the essay:

It is as if we took morphine to help us sleep on a bed of nails. Another generation would have looked for another solution.

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Sitting still

Over the past year I’ve had several conversations with people who work in our school district about our district’s behavioral rewards program (also known as “PBIS” -- those red tickets that I’ve been harping on in this space). Often these people -- many of whom I like and respect -- respond to my concerns with some variant of the following: “Yes, I understand why you don’t like it, and I’m not crazy about it either, but, you know, I work in the schools, and I can tell you, it really does work. The fact is, the teachers need something like this to get the kids to sit still long enough to learn the material.”

Notice the premise: If the kids can’t meet expectations, we need to change the kids. Isn’t it possible that there’s something wrong with the expectations, not with the kids? It is as if that possibility has been removed from the realm of permissible thoughts.

In his latest post, Peter Gray notes that approximately thirteen percent of American boys aged 4-18 have been diagnosed with attention deficit/hyperactivity disorder (ADHD). Gray writes:

How convenient that we have this official way of diagnosing kids who don’t sit still in their seats, often fail to pay attention to the teacher, don’t regularly do the assignments given to them, often speak out of turn, and blurt out answers before the questions are finished. They used to be called “naughty”--sometimes with a frown, sometimes with a smile of recognition that “kids will be kids” or “boys will be boys”--but now we know that they are, for biological reasons, mentally disordered.

The whole post is worth reading. Gray’s blog is always interesting because it raises the question that usually goes unasked: What is the great benefit of all this sitting still? Of all the coercion that (increasingly) underlies our system of compulsory education? Where is the evidence that it leads to a better world, or that it makes children more likely to grow into happy and fulfilled adults? I can understand how some people can disagree with him about these issues, but I don’t understand the lack of debate -- the near complete silence -- about this central feature of the way we’ve chosen to educate our kids.


..How can I comment?